SCIENTIFIC PAPER
Mesh Displacement After Bilateral Inguinal Hernia Repair With No Fixation Christiano Marlo Paggi Claus, MD, PhD, Gabriela Moreira Rocha, MD, Antonio Carlos Ligocki Campos, MD, PhD, Joa ˜o Augusto Nocera Paulin, MD, Julio Cesar Uili Coelho, MD, PhD ABSTRACT
of bilateral and unilateral NF groups did not show significant difference. Mean overall displacement was 1.9 cm versus 1.8 cm in the bilateral and unilateral NF groups, respectively (P ⫽ .78).
Background and Objectives: About 20% of patients with inguinal hernia present bilateral hernias in the diagnosis. In these cases, laparoscopic procedure is considered gold standard approach. Mesh fixation is considered important step toward avoiding recurrence. However, because of cost and risk of pain, real need for mesh fixation has been debated. For bilateral inguinal hernias, there are few specific data about non fixation and mesh displacement. We assessed mesh movement in patients who had undergone laparoscopic bilateral inguinal hernia repair without mesh fixation and compared the results with those obtained in patients with unilateral hernia.
Conclusions: TEP with no mesh fixation is safe in bilateral inguinal repairs. Early mesh displacement is minimal. This technique can be safely used in most patients with inguinal hernia. Key Words: Bilateral inguinal hernia, Inguinal hernia, Laparoscopy, Mesh fixation, Total extraperitoneal
INTRODUCTION
Methods: From January 2012 through May 2014, 20 consecutive patients with bilateral inguinal hernia underwent TEP repair with no mesh fixation. Results were compared with 50 consecutive patients with unilateral inguinal hernia surgically repaired with similar technique. Mesh was marked with 3 clips. Mesh movements were measured by comparing initial radiography performed at the end of surgery, with a second radiographic scan performed 30 days later.
Inguinal hernia repair is one of the most frequent elective operations performed in general surgical practice.1 Approximately 20% to 30% of patients with inguinal hernia present bilateral hernias at diagnosis.2,3 Although the indications of laparoscopic treatment of inguinal hernia remain controversial, most surgeons agree that patients with bilateral or recurrent inguinal hernia are those who benefit most from the laparoscopic approach, which is considered the gold standard for treating such cases.4 – 6
Results: Mean movements of all 3 clips in bilateral nonfixation (NF) group were 0.15– 0.4 cm compared with 0.1– 0.3 cm in unilateral NF group. Overall displacement
Recently, the need for and best way of fixing the mesh have been questioned. Mesh fixation with staples or tacks is traditionally used and may reduce the risk of mesh displacement, and consequently, decrease hernia recurrence.7,8 However, fixation is associated with higher costs and may increase the rate of acute and especially chronic pain.9,10
Minimally Invasive Surgery Department, Jacques Perissat Institute/Positivo University, Curitiba, Brazil (Dr. Claus). Radiology Department, Hospital Nossa Senhora das Grac¸as, Curitiba, Brazil (Dr. Rocha).
Several authors, in clinical trials, have shown no increased risk of recurrence in patients who underwent laparoscopic inguinal hernia repair (LIHR) with no mesh fixation.11–13 This finding is similar to our radiological study for unilateral hernias that showed minimal mesh displacement after total extraperitoneal (TEP) repair with no fixation, comparable to TEP with mesh fixation.14 However, there are few specific data in the literature regarding the necessity of mesh fixation in patients with bilateral inguinal hernia.15 In these cases, the wider dissection of
Department of Surgery, Universidade Federal do Parana´, Curitiba, Brazil (Drs. Campos and Coelho). Department of Surgery, Hospital Nossa Senhora das Grac¸as, Curitiba, Brazil (Dr. Paulin). Disclosures: none reported. Address correspondence to: Christiano Marlo Paggi Claus, MD, PhD, R. Comendador Araujo 143, conj 113, 80420-000, Curitiba PR, Brazil. Telephone: ⫹55-4196617777, Fax: ⫹55-41-33223789, E-mail: [email protected] DOI: 10.4293/JSLS.2017.00033 © 2017 by JSLS, Journal of the Society of Laparoendoscopic Surgeons. Published by the Society of Laparoendoscopic Surgeons, Inc.
July–September 2017 Volume 21 Issue 3 e2017.00033
1
JSLS www.SLS.org
Mesh Displacement After Bilateral Inguinal Hernia Repair With No Fixation, Claus C M P et al.
preperitoneal space could lead to a higher risk of mesh displacement. To answer this question, we designed a prospective and radiological clinical trial to assess mesh displacement in bilateral inguinal hernia repairs—TEP—with no mesh fixation. We also compared the results with those of nonfixed unilateral repairs.
METHODS From January 2012 through May 2014, 20 consecutive patients with bilateral inguinal hernia underwent TEP repair without mesh fixation. Results were compared with 50 consecutive patients with unilateral hernia who underwent totally extraperitoneal repairs without mesh fixation, during the same period. The results of these 50 patients have been published previously.14 The Medical Ethics Committee of Positivo University, Curitiba, Brazil, approved the study protocol. All patients signed the informed consent.
Figure 1. Mesh positioning and clips placed in one of the meshes. The indicators x and y represent the distances of the clips relative to the vertical and horizontal axes, respectively. Medical illustration by Rodrigo Tonan.
Patients with contraindications for general anesthesia, prior pelvic surgery, coagulopathy, inguinoscrotal hernias, or incarcerated or large hernias (lateral or medial defects larger than 3 cm— L3 or M3 according to the European Hernia Society classification) were excluded from the study.
while graspers held the mesh in position, the CO2 was removed, and the preperitoneal space was deflated. Radiological Evaluation
Surgical Technique
Distances of each clip in relation to 2 lines representing the vertical and horizontal axes (x and y) were measured (Figure 2). Differences in the distances between the first (performed at the end of procedure) and second (obtained 30 days later) x-rays represent the displacements of the clips: dx and dy. The same radiologist reviewed the x-rays.
After preinsufflation of the preperitoneal space with CO2 with a Verres needle placed in the suprapubic position, an infraumbilical incision was made to insert an 11-mm port for a 30° scope. Blunt dissection of the preperitoneal space was performed, including the right and left inguinal region, with 2 auxiliary 5-mm ports/graspers. The hernia was completely dissected and the cord structures exposed.
Detailed surgical and radiological techniques performed have been described.14
In the bilateral group, 2 meshes (Parietene; Medtronic, Minneapolis Minnesota, USA) were positioned crossing each other at the midline. Because of a possible difficulty in defining the clips, especially medially where the meshes intersect each other, we chose to mark only 1 of the meshes (the right side) with clips. The mesh was marked with 3-mm clips at its lateral inferior, medial inferior, and medial superior corners, the same marking technique that was used in the unilateral NF group (Figure 1). A mesh overlap of at least 3 to 4 cm was observed in relation to potential weakness areas. Mesh fixation was not employed in any patient. Under direct visualization, July–September 2017 Volume 21 Issue 3 e2017.00033
Statistical Analysis Mann-Whitney and Student t tests, Pearson’s Chi square test, and Fisher’s exact test, were used when appropriated. P ⬍ .05 was considered significant.
RESULTS Twenty patients presenting with bilateral inguinal hernias, and 50 patients with unilateral inguinal hernia underwent TEP repairs without mesh fixation. The mean ages of the bilateral and unilateral NF groups were 47.3 ⫾ 10.8 and 2
JSLS www.SLS.org
Table 2. Mesh Displacement After LIHR Clip/Axis
P*
Bilateral NF Group
Unilateral NF Group
(n ⫽ 20)
(n ⫽ 50)
Clip 1: dx
0.15 (0–0.50)
0.10 (0–0.70)
Clip 1: dy
0.20 (0–0.60)
0.20 (0–0.60)
.99
Clip 2: dx
0.30 (0–0.70)
0.30 (0–1.0)
.59
Clip 2: dy
0.40 (0–1.0)
0.30 (0–1.20)
.19
Clip 3: dx
0.30 (0–1.20)
0.30 (0–1.0)
.53
Clip 3: dy
0.40 (0–1.30)
0.30 (0–1.30)
.41
.84
*P ⬍ .05, by Mann-Whitney test. All are nonsignificant.
Figure 2. Pelvic radiograph showing the clips and performed measures, x and y in relation to the vertical and horizontal axes, respectively.
minutes (P ⬍ .001). There was no intraoperative complication and no conversion. The mean length of hospital stay was ⱕ24 h in all patients.
Table 1. Demographics and Operative Details
The postoperative surgical complication rate was similar in both groups. Only 3 patients in each group presented seroma/hematoma on postoperative day 7 (15% vs. 6%; P ⫽ .35). Seroma was reabsorbed spontaneously in all cases during the first month. There were no major postoperative complications. The mean interval between the 2 x-rays was 34.1 ⫾ 9.6 and 38.3 ⫾ 12.3 days for the bilateral and unilateral groups, respectively. Patients were observed for at least 3 months, and none of them had a recurrence.
P
Bilateral NF Group
Unilateral NF Group
(n ⫽ 20)
(n ⫽ 50)
Sex (M/F)
20/0
44/6
Age (years)
47.3 ⫾ 10.8 51.1 ⫾ 15.7 .60**
X-ray interval (days)
34.1 ⫾ 9.6
38.3 ⫾ 12.3 .36**
Previous hernia repair
1/20
3/50
.86*
II
3
14
.79***
IIIa
7
13
Mesh Displacement
IIIb
10
22
IIIc
0
1
Minimal changes in the position of the clips were observed when comparing the first and second x-ray. Mean displacement of all 3 clips in the bilateral NF group was 0.15 to 0.4 (range, 0 –1.3) cm, whereas in the unilateral NF group was 0.1– 0.3 (range, 0 –1.3) cm. No significant difference of any individual clip movement was observed, on vertical (dy) or horizontal (dx) directions between the bilateral and unilateral group (Table 2). As well, no differences were observed between the groups when dx ⫹ dy of each clip was analyzed (Table 3). The overall clip displacement (dx ⫹ dy: clips 1 ⫹ 2 ⫹ 3) in the bilateral NF and unilateral NF groups did not show a significant difference (Figure 3). Mean overall displacement was 1.9 (range, 0.9 –3.7) cm versus 1.8 (range, 0.7–3.3) cm in bilateral and unilateral NF groups, respectively (P ⫽ .78; Mann-Whitney test).
.14*
Nihus classification, n
Operative time (minutes)
48.7 ⫾ 10.2 38.7 ⫾ 8.8
Postoperative complication 3/20
3/50
Mesh Displacement After Bilateral Inguinal Hernia Repair With No Fixation Christiano Marlo Paggi Claus, MD, PhD, Gabriela Moreira Rocha, MD, Antonio Carlos Ligocki Campos, MD, PhD, Joa ˜o Augusto Nocera Paulin, MD, Julio Cesar Uili Coelho, MD, PhD ABSTRACT
of bilateral and unilateral NF groups did not show significant difference. Mean overall displacement was 1.9 cm versus 1.8 cm in the bilateral and unilateral NF groups, respectively (P ⫽ .78).
Background and Objectives: About 20% of patients with inguinal hernia present bilateral hernias in the diagnosis. In these cases, laparoscopic procedure is considered gold standard approach. Mesh fixation is considered important step toward avoiding recurrence. However, because of cost and risk of pain, real need for mesh fixation has been debated. For bilateral inguinal hernias, there are few specific data about non fixation and mesh displacement. We assessed mesh movement in patients who had undergone laparoscopic bilateral inguinal hernia repair without mesh fixation and compared the results with those obtained in patients with unilateral hernia.
Conclusions: TEP with no mesh fixation is safe in bilateral inguinal repairs. Early mesh displacement is minimal. This technique can be safely used in most patients with inguinal hernia. Key Words: Bilateral inguinal hernia, Inguinal hernia, Laparoscopy, Mesh fixation, Total extraperitoneal
INTRODUCTION
Methods: From January 2012 through May 2014, 20 consecutive patients with bilateral inguinal hernia underwent TEP repair with no mesh fixation. Results were compared with 50 consecutive patients with unilateral inguinal hernia surgically repaired with similar technique. Mesh was marked with 3 clips. Mesh movements were measured by comparing initial radiography performed at the end of surgery, with a second radiographic scan performed 30 days later.
Inguinal hernia repair is one of the most frequent elective operations performed in general surgical practice.1 Approximately 20% to 30% of patients with inguinal hernia present bilateral hernias at diagnosis.2,3 Although the indications of laparoscopic treatment of inguinal hernia remain controversial, most surgeons agree that patients with bilateral or recurrent inguinal hernia are those who benefit most from the laparoscopic approach, which is considered the gold standard for treating such cases.4 – 6
Results: Mean movements of all 3 clips in bilateral nonfixation (NF) group were 0.15– 0.4 cm compared with 0.1– 0.3 cm in unilateral NF group. Overall displacement
Recently, the need for and best way of fixing the mesh have been questioned. Mesh fixation with staples or tacks is traditionally used and may reduce the risk of mesh displacement, and consequently, decrease hernia recurrence.7,8 However, fixation is associated with higher costs and may increase the rate of acute and especially chronic pain.9,10
Minimally Invasive Surgery Department, Jacques Perissat Institute/Positivo University, Curitiba, Brazil (Dr. Claus). Radiology Department, Hospital Nossa Senhora das Grac¸as, Curitiba, Brazil (Dr. Rocha).
Several authors, in clinical trials, have shown no increased risk of recurrence in patients who underwent laparoscopic inguinal hernia repair (LIHR) with no mesh fixation.11–13 This finding is similar to our radiological study for unilateral hernias that showed minimal mesh displacement after total extraperitoneal (TEP) repair with no fixation, comparable to TEP with mesh fixation.14 However, there are few specific data in the literature regarding the necessity of mesh fixation in patients with bilateral inguinal hernia.15 In these cases, the wider dissection of
Department of Surgery, Universidade Federal do Parana´, Curitiba, Brazil (Drs. Campos and Coelho). Department of Surgery, Hospital Nossa Senhora das Grac¸as, Curitiba, Brazil (Dr. Paulin). Disclosures: none reported. Address correspondence to: Christiano Marlo Paggi Claus, MD, PhD, R. Comendador Araujo 143, conj 113, 80420-000, Curitiba PR, Brazil. Telephone: ⫹55-4196617777, Fax: ⫹55-41-33223789, E-mail: [email protected] DOI: 10.4293/JSLS.2017.00033 © 2017 by JSLS, Journal of the Society of Laparoendoscopic Surgeons. Published by the Society of Laparoendoscopic Surgeons, Inc.
July–September 2017 Volume 21 Issue 3 e2017.00033
1
JSLS www.SLS.org
Mesh Displacement After Bilateral Inguinal Hernia Repair With No Fixation, Claus C M P et al.
preperitoneal space could lead to a higher risk of mesh displacement. To answer this question, we designed a prospective and radiological clinical trial to assess mesh displacement in bilateral inguinal hernia repairs—TEP—with no mesh fixation. We also compared the results with those of nonfixed unilateral repairs.
METHODS From January 2012 through May 2014, 20 consecutive patients with bilateral inguinal hernia underwent TEP repair without mesh fixation. Results were compared with 50 consecutive patients with unilateral hernia who underwent totally extraperitoneal repairs without mesh fixation, during the same period. The results of these 50 patients have been published previously.14 The Medical Ethics Committee of Positivo University, Curitiba, Brazil, approved the study protocol. All patients signed the informed consent.
Figure 1. Mesh positioning and clips placed in one of the meshes. The indicators x and y represent the distances of the clips relative to the vertical and horizontal axes, respectively. Medical illustration by Rodrigo Tonan.
Patients with contraindications for general anesthesia, prior pelvic surgery, coagulopathy, inguinoscrotal hernias, or incarcerated or large hernias (lateral or medial defects larger than 3 cm— L3 or M3 according to the European Hernia Society classification) were excluded from the study.
while graspers held the mesh in position, the CO2 was removed, and the preperitoneal space was deflated. Radiological Evaluation
Surgical Technique
Distances of each clip in relation to 2 lines representing the vertical and horizontal axes (x and y) were measured (Figure 2). Differences in the distances between the first (performed at the end of procedure) and second (obtained 30 days later) x-rays represent the displacements of the clips: dx and dy. The same radiologist reviewed the x-rays.
After preinsufflation of the preperitoneal space with CO2 with a Verres needle placed in the suprapubic position, an infraumbilical incision was made to insert an 11-mm port for a 30° scope. Blunt dissection of the preperitoneal space was performed, including the right and left inguinal region, with 2 auxiliary 5-mm ports/graspers. The hernia was completely dissected and the cord structures exposed.
Detailed surgical and radiological techniques performed have been described.14
In the bilateral group, 2 meshes (Parietene; Medtronic, Minneapolis Minnesota, USA) were positioned crossing each other at the midline. Because of a possible difficulty in defining the clips, especially medially where the meshes intersect each other, we chose to mark only 1 of the meshes (the right side) with clips. The mesh was marked with 3-mm clips at its lateral inferior, medial inferior, and medial superior corners, the same marking technique that was used in the unilateral NF group (Figure 1). A mesh overlap of at least 3 to 4 cm was observed in relation to potential weakness areas. Mesh fixation was not employed in any patient. Under direct visualization, July–September 2017 Volume 21 Issue 3 e2017.00033
Statistical Analysis Mann-Whitney and Student t tests, Pearson’s Chi square test, and Fisher’s exact test, were used when appropriated. P ⬍ .05 was considered significant.
RESULTS Twenty patients presenting with bilateral inguinal hernias, and 50 patients with unilateral inguinal hernia underwent TEP repairs without mesh fixation. The mean ages of the bilateral and unilateral NF groups were 47.3 ⫾ 10.8 and 2
JSLS www.SLS.org
Table 2. Mesh Displacement After LIHR Clip/Axis
P*
Bilateral NF Group
Unilateral NF Group
(n ⫽ 20)
(n ⫽ 50)
Clip 1: dx
0.15 (0–0.50)
0.10 (0–0.70)
Clip 1: dy
0.20 (0–0.60)
0.20 (0–0.60)
.99
Clip 2: dx
0.30 (0–0.70)
0.30 (0–1.0)
.59
Clip 2: dy
0.40 (0–1.0)
0.30 (0–1.20)
.19
Clip 3: dx
0.30 (0–1.20)
0.30 (0–1.0)
.53
Clip 3: dy
0.40 (0–1.30)
0.30 (0–1.30)
.41
.84
*P ⬍ .05, by Mann-Whitney test. All are nonsignificant.
Figure 2. Pelvic radiograph showing the clips and performed measures, x and y in relation to the vertical and horizontal axes, respectively.
minutes (P ⬍ .001). There was no intraoperative complication and no conversion. The mean length of hospital stay was ⱕ24 h in all patients.
Table 1. Demographics and Operative Details
The postoperative surgical complication rate was similar in both groups. Only 3 patients in each group presented seroma/hematoma on postoperative day 7 (15% vs. 6%; P ⫽ .35). Seroma was reabsorbed spontaneously in all cases during the first month. There were no major postoperative complications. The mean interval between the 2 x-rays was 34.1 ⫾ 9.6 and 38.3 ⫾ 12.3 days for the bilateral and unilateral groups, respectively. Patients were observed for at least 3 months, and none of them had a recurrence.
P
Bilateral NF Group
Unilateral NF Group
(n ⫽ 20)
(n ⫽ 50)
Sex (M/F)
20/0
44/6
Age (years)
47.3 ⫾ 10.8 51.1 ⫾ 15.7 .60**
X-ray interval (days)
34.1 ⫾ 9.6
38.3 ⫾ 12.3 .36**
Previous hernia repair
1/20
3/50
.86*
II
3
14
.79***
IIIa
7
13
Mesh Displacement
IIIb
10
22
IIIc
0
1
Minimal changes in the position of the clips were observed when comparing the first and second x-ray. Mean displacement of all 3 clips in the bilateral NF group was 0.15 to 0.4 (range, 0 –1.3) cm, whereas in the unilateral NF group was 0.1– 0.3 (range, 0 –1.3) cm. No significant difference of any individual clip movement was observed, on vertical (dy) or horizontal (dx) directions between the bilateral and unilateral group (Table 2). As well, no differences were observed between the groups when dx ⫹ dy of each clip was analyzed (Table 3). The overall clip displacement (dx ⫹ dy: clips 1 ⫹ 2 ⫹ 3) in the bilateral NF and unilateral NF groups did not show a significant difference (Figure 3). Mean overall displacement was 1.9 (range, 0.9 –3.7) cm versus 1.8 (range, 0.7–3.3) cm in bilateral and unilateral NF groups, respectively (P ⫽ .78; Mann-Whitney test).
.14*
Nihus classification, n
Operative time (minutes)
48.7 ⫾ 10.2 38.7 ⫾ 8.8
Postoperative complication 3/20
3/50
